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Cardiovascular > Week 5 > Flashcards

Week 5 Flashcards

1
Q

What is a heart murmur?

A

The audible manifestation of turbulent blood flow within—or immediately adjacent to—the cardiac chambers or great vessels.

Turbulence arises from increased flow velocity or disruption of the normal laminar stream due to anatomic or hemodynamic factors.

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2
Q

What causes turbulence in blood flow leading to murmurs?

A

Turbulence can arise from:
* High-velocity flow through a narrow orifice (e.g., aortic stenosis)
* Flow across an abnormal communication (e.g., ventricular septal defect)
* Regurgitant flow through incompetent valves (e.g., mitral regurgitation)
* Increased flow states (e.g., anemia, fever, thyrotoxicosis)

These conditions create eddies that generate vibrations, producing an audible sound.

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3
Q

How does inspiration affect left-sided murmurs?

A

Decreases intensity due to reduced left ventricular filling.

This occurs because inspiration decreases intrathoracic pressure and increases venous return to the right heart.

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4
Q

How does inspiration affect right-sided murmurs?

A

Increases intensity due to increased right ventricular output (Carvallo’s sign).

The increase in venous return to the right heart during inspiration enhances right-sided murmur sounds.

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5
Q

What effect does expiration have on left-sided murmurs?

A

Increases intensity due to increased left ventricular filling.

Expiration increases intrathoracic pressure, leading to increased venous return to the left heart.

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6
Q

What effect does expiration have on right-sided murmurs?

A

Decreases intensity due to reduced right ventricular preload.

This is a result of the increased intrathoracic pressure during expiration.

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7
Q

What is the effect of the Valsalva maneuver on murmurs?

A

Decreases intensity of most murmurs (especially AS, MR) due to reduced venous return to both ventricles.

The Valsalva maneuver reduces venous return, impacting the sound intensity of murmurs.

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8
Q

What happens to left-sided murmurs during the release of the Valsalva maneuver?

A

Transiently increases intensity.

The sudden increase in venous return and afterload during the release phase affects murmur intensity.

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9
Q

What happens to right-sided murmurs during the release of the Valsalva maneuver?

A

Transiently increases intensity.

Similar to left-sided murmurs, the increase in venous return affects the intensity of right-sided murmurs.

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10
Q

What effect does isometric handgrip have on regurgitant murmurs?

A

Increases intensity of regurgitant murmurs (MR, AR, VSD).

Isometric handgrip increases systemic vascular resistance (afterload), impacting murmur sounds.

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11
Q

What effect does isometric handgrip have on stenotic murmurs?

A

Decreases intensity of stenotic murmurs (AS, HCM).

The increase in afterload during isometric handgrip affects the intensity of stenotic murmurs.

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12
Q

What effect does isometric handgrip have on tricuspid regurgitation (TR)?

A

Increases intensity due to more regurgitation.

The increased afterload enhances the sound of the regurgitant flow.

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13
Q

What is the mechanism of the third heart sound (S₃)?

A

Rapid deceleration of blood against the compliant ventricular wall during early diastole

Occurs during the rapid-filling phase of the heart cycle.

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14
Q

When is S₃ considered normal?

A

In children and young adults (< 40 years) at physiologic heart rates

It is a normal finding in younger populations.

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15
Q

What does the presence of S₃ indicate in patients aged ≥ 40 years?

A

Ventricular volume overload or reduced compliance

Examples include dilated cardiomyopathy and post-myocardial infarction.

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16
Q

What is the mechanism of the fourth heart sound (S₄)?

A

Atrial contraction ejects blood against a noncompliant, hypertrophied, or ischemic ventricle in late diastole

This is referred to as the ‘atrial kick’.

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17
Q

When is S₄ considered pathologic?

A

Always pathologic

It indicates conditions of reduced ventricular compliance.

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18
Q

List conditions associated with S₄.

A
  • Left ventricular hypertrophy
  • Aortic stenosis
  • Ischemic heart disease
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19
Q

What is the timing and shape of aortic stenosis (AS) murmur?

A

Systolic, crescendo–decrescendo (“diamond-shaped”)

It is best heard at the right upper sternal border.

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20
Q

Where is mitral regurgitation (MR) murmur best heard?

A

Apex

It radiates to the left axilla.

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21
Q

What happens to the mitral regurgitation (MR) murmur with handgrip?

A

Increases

This maneuver increases systemic vascular resistance.

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22
Q

Describe the murmur associated with mitral stenosis (MS).

A

Diastolic, low-frequency “rumble” with opening snap, early diastolic accentuation

Best heard at the apex in left lateral decubitus position.

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23
Q

What effect does expiration have on mitral stenosis (MS) murmur?

A

Increases

It decreases with Valsalva maneuver.

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24
Q

What is the location for aortic regurgitation (AR) murmur?

A

Left sternal border (3rd–4th ICS)

It is characterized by an early diastolic, decrescendo “blowing” sound.

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25
What is the characteristic of tricuspid regurgitation (TR) murmur?
Holosystolic, high-pitched “blowing,” augmented by inspiration ## Footnote Known as Carvallo’s sign.
26
Where is tricuspid stenosis (TS) murmur best heard?
Left sternal border (4th ICS) ## Footnote It is a diastolic rumble with opening snap.
27
What is the murmur shape of pulmonic stenosis (PS)?
Systolic, crescendo–decrescendo ## Footnote Best heard at the left sternal border (2nd–3rd ICS).
28
What is the characteristic of a small ventricular septal defect (VSD) murmur?
Harsh holosystolic, loudest at tricuspid area ## Footnote It is best heard at the left lower sternal border.
29
What effect does handgrip have on small VSD murmur?
Increases ## Footnote It may also increase with expiration.
30
What is the definition of Aortic Stenosis (AS)?
Fixed obstruction of left ventricular outflow across the aortic valve, most often due to leaflet calcification or congenital bicuspid morphology.
31
What is the prevalence of degenerative calcific Aortic Stenosis in patients over 65 years old?
Prevalence rises sharply with age (2–7% over age 65).
32
What percentage of the population is affected by a bicuspid aortic valve?
Affects 1–2% of the population.
33
How does the presentation of Aortic Stenosis differ between bicuspid and tricuspid valves?
Presents with AS 10–20 years earlier than tricuspid degenerative AS.
34
In which regions is rheumatic Aortic Stenosis more common?
Less common in developed countries.
35
What are the main causes of Aortic Stenosis?
* Age‐related calcific degeneration * Congenital bicuspid or unicuspid valve * Rheumatic heart disease
36
What is the pathophysiology behind Aortic Stenosis?
* Pressure overload → concentric LV hypertrophy to maintain wall stress (Law of Laplace) * Increased LV diastolic pressure → reduced compliance, diastolic dysfunction * Eventually LV failure → increased left atrial pressure → pulmonary congestion and right‐sided failure in advanced disease
37
What are the classic triad symptoms indicating severe Aortic Stenosis?
* Angina (due to supply–demand mismatch from hypertrophy) * Syncope or presyncope (often exertional; fixed cardiac output) * Heart failure symptoms (dyspnea on exertion, orthopnea)
38
What are the physical exam findings in Aortic Stenosis?
* Delayed, weak carotid upstroke (“pulsus parvus et tardus”) * Harsh systolic ejection murmur radiating to carotids * Soft or absent S₂
39
What is the echocardiographic criterion for severe Aortic Stenosis based on valve area?
Valve area (≤ 1.0 cm² severe).
40
What peak velocity on echocardiography indicates severe Aortic Stenosis?
Peak velocity (≥ 4 m/s severe).
41
What mean gradient on echocardiography indicates severe Aortic Stenosis?
Mean gradient (≥ 40 mm Hg severe).
42
What ECG finding is typical in patients with Aortic Stenosis?
Left ventricular hypertrophy (LVH).
43
What chest X-ray findings are associated with Aortic Stenosis?
* Post‑stenotic aortic dilation * Calcification
44
What is the management strategy for asymptomatic mild to moderate Aortic Stenosis?
Surveillance with periodic echo (every 1–3 years as indicated).
45
What is the definitive treatment for symptomatic or severe Aortic Stenosis?
Aortic valve replacement (AVR) either surgical AVR (SAVR) or transcatheter AVR (TAVR) based on surgical risk and anatomy.
46
What is a potential bridge procedure in select young or high-risk patients with Aortic Stenosis?
Balloon valvuloplasty.
47
What medical management is advised for patients with Aortic Stenosis?
* Afterload reduction (cautious) * Treat comorbid hypertension * Avoid vasodilators in severe symptomatic AS due to risk of hypotension.
48
What is the definition of Mitral Stenosis (MS)?
Obstruction to flow across the mitral valve during diastole, most commonly due to fusion and thickening of valve leaflets and chordae.
49
What is the predominant etiology of Mitral Stenosis?
Rheumatic fever (> 95% in endemic areas).
50
What is the peak incidence age range for Mitral Stenosis post-rheumatic fever?
20–40 years.
51
What are the major causes of Mitral Stenosis?
* Rheumatic fever * Congenital MS * Severe mitral annular calcification
52
What is the pathophysiological consequence of diastolic transmitral gradient in Mitral Stenosis?
Increased left atrial (LA) pressure leading to LA enlargement.
53
What are the clinical symptoms of Mitral Stenosis?
* Exertional dyspnea * Orthopnea * Paroxysmal nocturnal dyspnea * Hemoptysis * Fatigue
54
What are the characteristic signs of Mitral Stenosis?
* Loud S₁ * Opening snap followed by diastolic rumble * Signs of right-sided failure in advanced disease * Atrial fibrillation with irregularly irregular pulse
55
What echocardiographic finding indicates severe Mitral Stenosis?
Mitral valve area by pressure half-time < 1.5 cm².
56
What ECG finding is associated with Mitral Stenosis?
Left atrial enlargement (P-mitrale) and atrial fibrillation.
57
What chest X-ray finding is indicative of Mitral Stenosis?
Left atrial enlargement ('double shadow') and pulmonary venous congestion.
58
What medical management is indicated for pulmonary congestion in Mitral Stenosis?
Diuretics.
59
What medications are used for rate control in atrial fibrillation associated with Mitral Stenosis?
* Beta-blockers * Nondihydropyridine calcium channel blockers (CCBs)
60
When is anticoagulation indicated in Mitral Stenosis?
If atrial fibrillation or left atrial thrombus is present.
61
What is the interventional management for Mitral Stenosis in suitable anatomy?
Percutaneous balloon mitral valvotomy (Wilkins score ≤ 8).
62
What surgical options are available for Mitral Stenosis if percutaneous approach is unsuitable?
* Surgical commissurotomy * Valve replacement
63
What is the definition of Aortic Regurgitation (AR)?
Backward flow of blood from the aorta into the LV during diastole owing to valve or aortic root incompetence. ## Footnote LV stands for left ventricle.
64
What are the causes of Acute Aortic Regurgitation?
* Infective endocarditis * Aortic dissection * Trauma ## Footnote Acute AR can occur suddenly due to these conditions.
65
What are the causes of Chronic Aortic Regurgitation?
* Bicuspid aortic valve * Rheumatic disease * Aortic root dilation (Marfan’s, syphilis, hypertension) ## Footnote Chronic AR develops over time due to these underlying conditions.
66
What is the pathophysiology of Aortic Regurgitation?
* Volume overload of LV * Eccentric hypertrophy * Increased compliance maintains stroke volume initially * Over time: ↑ diastolic wall stress → LV dilation, systolic dysfunction ## Footnote LV stands for left ventricle.
67
What are the clinical features of Acute Aortic Regurgitation?
* Flash pulmonary edema * Cardiogenic shock ## Footnote These features indicate a sudden worsening of heart function.
68
What are the clinical features of Chronic Aortic Regurgitation?
* Wide pulse pressure (e.g., water-hammer pulses, capillary pulsations) * Murmur: Early diastolic, decrescendo at LSB; Austin Flint murmur (mid-diastolic rumble at apex) ## Footnote LSB stands for left sternal border.
69
What diagnostic tools are used for Aortic Regurgitation?
* Echo: Regurgitant volume and fraction; vena contracta; effective regurgitant orifice; LV size and function * CXR: LV enlargement, pulmonary edema if acute * ECG: LVH ## Footnote LVH stands for left ventricular hypertrophy.
70
What is the management for Acute Aortic Regurgitation?
* Emergent afterload reduction (IV vasodilators) * Urgent surgical AVR ## Footnote AVR stands for aortic valve replacement.
71
What is the medical management for Chronic Aortic Regurgitation?
* Afterload reduction (ACE inhibitors, hydralazine) to delay progression ## Footnote ACE inhibitors are a class of medications that help relax blood vessels.
72
When is surgical intervention indicated for Chronic Aortic Regurgitation?
* LV ejection fraction ≤ 50% * End-systolic dimension > 50 mm * Onset of symptoms ## Footnote These criteria are used to assess the severity of AR and the need for surgery.
73
What is the definition of Mitral Regurgitation (MR)?
Retrograde blood flow from LV into LA during systole through an incompetent mitral valve.
74
What are the two types of Mitral Regurgitation?
* Primary (organic) MR * Secondary (functional) MR
75
What are the causes of Primary (organic) Mitral Regurgitation?
* Degenerative (myxomatous) * Rheumatic * Endocarditis * Papillary muscle rupture
76
What are the causes of Secondary (functional) Mitral Regurgitation?
* LV dilation/dysfunction post-MI * Cardiomyopathy
77
What are the main causes of Mitral Regurgitation?
* Valve leaflet pathology * Chordae tendineae rupture * Papillary muscle dysfunction * Annular dilation
78
What is the pathophysiology of Mitral Regurgitation?
* LA volume overload → LA dilation, ↑ compliance * LV volume overload → eccentric hypertrophy; maintenance of forward output until late decompensation
79
What are common symptoms of Mitral Regurgitation?
* Dyspnea * Fatigue * Palpitations (from AF) * Orthopnea
80
What signs are indicative of Mitral Regurgitation?
* Holosystolic 'blowing' murmur at apex radiating to axilla * S₃ gallop * Signs of pulmonary congestion
81
What is the role of echocardiography in the diagnosis of Mitral Regurgitation?
Quantification of regurgitant volume/fraction; vena contracta width; effective regurgitant orifice; LA/LV size and function.
82
What ECG findings are associated with Mitral Regurgitation?
LA enlargement, AF.
83
What chest X-ray findings may indicate Mitral Regurgitation?
LA and LV enlargement, pulmonary edema in acute MR.
84
What medical management options are available for Mitral Regurgitation?
* Afterload reduction (vasodilators) * Diuretics to manage pulmonary congestion * Rate/rhythm control in AF * Anticoagulation if indicated
85
What is the preferred surgical intervention for primary Mitral Regurgitation with suitable anatomy?
Mitral valve repair.
86
When is mitral valve replacement indicated in Mitral Regurgitation?
When repair is not feasible.
87
What is a percutaneous option for treating Mitral Regurgitation in select high-risk patients?
Percutaneous edge-to-edge repair (e.g., MitraClip).
88
What is the definition of Tricuspid Regurgitation (TR)?
Retrograde flow from RV into RA during systole through an incompetent tricuspid valve.
89
What is the most common type of Tricuspid Regurgitation?
Functional TR secondary to RV dilation.
90
What are some causes of Organic Tricuspid Regurgitation?
* Rheumatic disease * Endocarditis * Carcinoid syndrome * Congenital
91
What is the pathophysiology of Tricuspid Regurgitation?
* RA volume overload * RA dilation * Systemic venous congestion * RV volume overload may lead to frank RV dysfunction
92
What are common symptoms of Tricuspid Regurgitation?
* Fatigue * Abdominal discomfort * Peripheral edema
93
What signs may indicate Tricuspid Regurgitation?
* Holosystolic murmur along left lower sternal border * Intensifies with inspiration (Carvallo’s sign) * Prominent v-waves in jugular venous pulse * Pulsatile liver
94
What diagnostic tools are used for Tricuspid Regurgitation?
* Echo * Doppler * ECG/CXR
95
What does an echocardiogram assess in Tricuspid Regurgitation?
* Degree of regurgitation * Annular diameter * RV size/function
96
What is a medical management strategy for Tricuspid Regurgitation?
* Salt restriction * Diuretics for volume overload * Treat underlying left‐sided disease or pulmonary hypertension
97
What are the surgical/interventional options for managing Tricuspid Regurgitation?
* Annuloplasty or valve repair preferred over replacement * Replacement if repair not feasible * Percutaneous approaches under investigation
98
True or False: RA dilation is a consequence of RA volume overload in Tricuspid Regurgitation.
True
99
Fill in the blank: The main cause of Functional Tricuspid Regurgitation is _______.
RV dilation
100
What might ECG/CXR show in a patient with Tricuspid Regurgitation?
RA/RV enlargement
101
What is the initial method for detecting and characterizing murmurs in valvular heart disease?
Cardiac Auscultation ## Footnote Cardiac auscultation helps assess the timing, quality, and radiation of murmurs.
102
Which diagnostic tool is considered the gold standard for anatomic and hemodynamic assessment in valvular heart disease?
Transthoracic & Transesophageal Echocardiography ## Footnote These echocardiographic techniques provide detailed information on heart structure and function.
103
What findings can be observed on a Chest X-Ray in valvular heart disease?
Chamber enlargement, pulmonary vascular congestion, calcification ## Footnote These findings indicate structural changes in the heart and lungs.
104
What does an Electrocardiogram typically reveal in patients with valvular heart disease?
Chamber hypertrophy, arrhythmias (e.g., AF) ## Footnote AF stands for atrial fibrillation, a common arrhythmia associated with valvular heart conditions.
105
What advanced imaging techniques provide detailed anatomy and quantification of regurgitant volumes?
Cardiac MRI/CT ## Footnote These modalities are useful for assessing suitability for transcatheter procedures.
106
What pathological finding is associated with degenerative aortic stenosis?
Calcification (leaflet and annular) ## Footnote Calcification leads to stiffening of the valve, impeding blood flow.
107
What pathological changes are seen in rheumatic mitral stenosis?
Sclerosis and Leaflet Thickening, Leaflet Fusion/Commissural Fusion ## Footnote These changes contribute to the narrowing of the mitral valve opening.
108
What is the cause of annular dilation in functional mitral regurgitation?
Ventricular remodeling ## Footnote This remodeling occurs due to pressure or volume overload.
109
What is a chordal rupture and in which condition is it commonly found?
Flail leaflet in degenerative mitral regurgitation ## Footnote Chordal rupture leads to severe regurgitation and potential heart failure.
110
What management option involves observation and risk-factor control?
Conservative management in mild disease ## Footnote This approach is often taken when symptoms are not severe.
111
What type of medication is used for afterload reduction in aortic regurgitation and mitral regurgitation?
Vasodilators ## Footnote These medications help reduce the workload on the heart.
112
What is the purpose of diuretics in the management of valvular heart disease?
For volume overload ## Footnote Diuretics help reduce fluid retention and lower blood pressure.
113
What is TAVR and in which patients is it indicated?
Transcatheter Aortic Valve Replacement; for high/intermediate surgical-risk severe aortic stenosis ## Footnote TAVR is a minimally invasive procedure for valve replacement.
114
What is the MitraClip used for?
Edge-to-edge repair in select mitral regurgitation patients unfit for surgery ## Footnote This percutaneous intervention helps reduce regurgitation.
115
What is the preferred surgical option for mitral and tricuspid regurgitation when feasible?
Valve repair ## Footnote Repair is often preferred over replacement due to better outcomes.
116
What are the two types of valve replacement options?
Mechanical and bioprosthetic ## Footnote Mechanical valves are durable but require lifelong anticoagulation, while bioprosthetic valves have limited durability.
117
What is a common complication of valvular heart disease that involves pressure or volume overload?
Heart Failure ## Footnote This can lead to systolic or diastolic dysfunction depending on the type of overload.
118
What type of arrhythmia is commonly associated with mitral stenosis and mitral regurgitation?
Atrial fibrillation ## Footnote AF increases the risk of thromboembolism and stroke.
119
What is the remodeling pattern seen in aortic stenosis?
Concentric hypertrophy ## Footnote This occurs as the left ventricle adapts to increased pressure load.
120
What leads to eccentric hypertrophy in aortic and mitral regurgitation?
Volume overload ## Footnote This hypertrophy can ultimately lead to pump failure.
121
What complication is characterized by backward transmission of elevated pressures?
Pulmonary Hypertension ## Footnote Conditions like mitral stenosis and tricuspid regurgitation can lead to this complication.
122
What condition poses a high risk for infective endocarditis?
Damaged valves ## Footnote Valvular damage creates a substrate for bacterial colonization.
123
What complication can occur due to left atrial thrombus formation in mitral stenosis with atrial fibrillation?
Thromboembolism ## Footnote This can result in stroke or other systemic embolic events.

Cardiovascular (12 decks)

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